The National Quality Forum (NQF) held an in-person meeting in Washington, DC, May 10-11, 2016, to re-evaluate 16 palliative & end-of-life care performance measures. Information about the measures being evaluated, the NQF process, and the NQF Standing Committee roster can be found on the NQF website.  AAHPM leaders Christine Ritchie, Paul Tatum, Gregg VandeKieft, and others were chosen to take part in the NQF Standing Committee.  AAHPM had previously submitted comments for the Standing Committee to consider, and AAHPM staff Katherine Ast, Director of Quality & Research, was on hand at the meeting to deliver additional comments:

“AAHPM and other organizations from the National Coalition of Hospice and Palliative Care are here to express our strong support for the continued endorsement of all the measures brought forward for maintenance in this project.  Please take note of the letter we submitted prior to this meeting which highlights some of the issues our field faces that contribute to our lack of relevant measures, particularly those with a true palliative care denominator. What we want to emphasize today is how critical it is that we keep the endorsement of the measures we do have so they can be used to improve the quality of care for our patients and families and to enable our clinicians to participate in value-based reimbursement.

NQF, CMS and the MAP have indicated though various publications and rule-making that palliative and end-of-life care represents a major gap in quality measurement. NQF & CMS have also called for measures to become more cross-cutting. Our field is very unique since our patients are all seriously ill and death is not always a negative outcome, and can likely be a neutral or positive outcome. We need measures that are flexible, take patient preferences into account, emphasize care coordination, family meetings, goals of care, etc. The approach to measure development for our field cannot be cookie cutter. In order to increase the usability of the measures we have and expand the settings and populations for which they can be implemented, we need to keep working with what we have.

We have so few outcome measures in our field, particularly patient-reported measures and for good reasons. However, we do have NQF #0209 which is able to capture patient self-report of pain. No, it can’t capture every patient so other measures need to be developed. But it does capture patient self-report of patients who can report. NQF staff Karen Johnson asked the question at the beginning of today’s meeting that if we had outcome measures to capture enough aspects of the quality of care for patients with serious illness, would we still need process measures? Unfortunately, we have so few outcome measures, that we couldn’t possibly dispose of our process measures to measure quality. However, we do have this outcome measure and we should keep it. We believe that risk adjustment or risk stratification is not critical for this or any other measures brought forth today, although it is currently being explored for several of the measures. The measures are used for comparison among similar providers and there is no expectation that performance will be 100%.

Benchmarking is a critical component to measuring the quality of care and without measures to report and data to aggregate, we can never get to any benchmarks in our field. There are certain processes that many believe should continue to be measured, even up to a rate of 100%. (For example, not having an ICD deactivated before an expected death most consider a “never event” and yet it still happens.) What does it mean for a measure to be topped out? With such a new field still finding its place in health care and in different settings, we think all the measures are far from being topped out, even if they approach 100% performance. In addition, many measures continue to show a clear opportunity for improvement. Once we expand the measures to be reported in multiple settings and with a true palliative care denominator, then we can start to enable benchmarking and true comparison of providers. We’ll need to keep the endorsement of all the measures presented here today in order to see that goal become a reality.”

Questions? Contact Katherine Ast at kast@aahpm.org.